Immune Globulin (IG) Therapy Medication and/or Infusion ...

1 Aetna Precertification Notification Immune Globulin (IG) Therapy Medication 503 Sunport Lane, Orlando, FL 32809. and/or Infusion Precertification Request Phone: 1-866-503-0857. Page 1 of 3 FAX: 1-888-267-3277. (All fields must be completed and legible for Precertification Review.). For Medicare Advantage Part B: Please indicate: Start of treatment: Start date / / FAX: 1-844-268-7263. Continuation of Therapy : Date of last treatment / /. Precertification Requested By: Phone: Fax: A. PATIENT INFORMATION. First Name: Last Name: Address: City: State: ZIP: Home Phone: Work Phone: Cell Phone: DOB: Allergies: Email: Current Weight: lbs or kgs Height: inches or cms B. INSURANCE INFORMATION. Aetna Member ID #: Does patient have other coverage? Yes No Group #: If yes, provide ID#: Carrier Name: Insured: Insured: Medicare: Yes No If yes, provide ID #: Medicaid: Yes No If yes, provide ID #: C.

2 PRESCRIBER INFORMATION. First Name: Last Name: (Check One): Address: City: State: ZIP: Phone: Fax: St Lic #: NPI #: DEA #: UPIN: Provider Email: Office Contact Name: Phone: Specialty (Check one): Oncologist Hematologist Other: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Place of Administration: Dispensing Provider/Pharmacy: Patient Selected choice Self-administered Physician's Office Physician's Office Retail Pharmacy Outpatient Infusion Center Phone: Specialty Pharmacy Mail Order Center Name: Other: Home Infusion Center Phone: Name: Agency Name: Address: Administration code(s) (CPT): Phone: Fax: Address: TIN: PIN: E. PRODUCT INFORMATION. Request is for: Bivigam Carimune NF Cuvitru Flebogamma Gammaked Gammagard Gammaplex Gamunex Hizentra HyQvia Octagam Privigen Dose: Frequency: F.

3 DIAGNOSIS INFORMATION Please indicate primary ICD Code and specify any other where applicable. Primary ICD Code: Secondary ICD Code: Other ICD Code: G. CLINICAL INFORMATION Required clinical information must be completed in its entirety for all precertification requests. Please provide the current immunoglobulin levels: Immunoglobulin A (IgA) level and date obtained: Date: / /. Immunoglobulin G (IgG) level and date obtained: Date: / /. Immunoglobulin M (IgM) level and date obtained: Date: / /. For All Requests: (Clinical documentation required for all requests). Yes No Is the patient changing to a different Immunoglobulin product? Yes No Does the patient have immunoglobulin A (IgA) deficiency with anti-IgA antibodies? Yes No Is this Infusion request in an outpatient hospital setting?

4 Yes No Is the patient medically unstable for infusions at alternate levels of care? Yes No Does the patient have a history of any cardiopulmonary conditions? Please provide the description of the condition: Yes No Does this condition cause an increased risk of severe adverse reactions? Yes No Does the patient have documentation of unstable vascular access? Yes No Does the patient have physical or cognitive impairments such that home Infusion would present an unnecessary health risk? Please explain: Yes No Is there clinical evidence that the patient has an inability to safely tolerate intravenous volume load (including from unstable renal function)? Yes No Is the inability to tolerate intravenous volume load due to unstable renal function? 2. Please document the following: GFR: mL/ Date Collected: / /.

5 BUN: mg/dL Date Collected: / /. Creatinine: mg/dL Date Collected: / /. Continued on next page GR-68305 (9-17). Aetna Precertification Notification Immune Globulin (IG) Therapy Medication 503 Sunport Lane, Orlando, FL 32809. and/or Infusion Precertification Request Phone: 1-866-503-0857. Page 2 of 3 FAX: 1-888-267-3277. (All fields must be completed and legible for Precertification Review.). For Medicare Advantage Part B: FAX: 1-844-268-7263. Patient First Name Patient Last Name Patient Phone Patient DOB. G. CLINICAL INFORMATION (continued) Required clinical information must be completed in its entirety for all precertification requests. For All requests continued: Please indicate which of the following applies to the patient and answer subsequent questions Acquired red cell aplasia Acute disseminated encephalomyelitis Autoimmune mucocutaneous blistering disease Please select which applies to the patient: Bullous pemphigoid Epidermolysis bullosa aequisita Gestational Pemphigoid Linear IgA disease Mucous membrane pemphigoid (Cicatrical pemphigoid).

6 Pemphigus vulgaris Pemphigus folicaceus None of the above Yes No Has patient failed conventional Therapy ? Yes No Does the patient have contraindications to conventional Therapy ? Yes No Does the patient have rapidly progressive disease in which a clinical response could not be affected quickly enough using conventional agents? Autoimmune hemolytic anemia (refractory). Autoimmune neutropenia (refractory). B-cell chronic lymphocytic leukemia (CLL). Yes No Does the patient have hypogammaglobulinemia associated with CLL? Yes No Does the patient have recurrent infections or specific antibody deficiency? Birdshot (vitiligenous) retinochoroidopathy Chronic inflammatory demyelinating polyneuropathy (CIDP). Dermatomyositis Yes No Will this be used as adjunctive Therapy for persons who have had an inadequate response to first and second line therapies?

7 Churg-Strauss Syndrome (CSS) (allergic granulomatosis). Yes No Will this be used as adjunctive Therapy for persons with severe active illness? Yes No Have other interventions been unsuccessful, become intolerable, or are contraindicated? Please select below which applies: Unsuccessful Intolerable Contraindicated Enteroviral meningoencephalitis Guillain-Barre Syndrome (GBS) and GBS variants Yes No Has the patient been diagnosed during the first 2 weeks of illness? Yes No Does the patient require aid to walk? Yes No Does the patient have any contraindications to IVIG? Hemolytic disease of newborn Yes No Is this request to decrease the need for exchange transfusion? HIV infected children Yes No Is this request for bacterial control or prevention of infection?

8 HIV- associated thrombocytopenia (pediatric or adult). Hyperimmunoglobulinemia E Syndrome Yes No Is this request for treatment of severe eczema? Immune or Idiopathic thrombocytopenic purpura (ITP). Yes No Is a rapid rise in platelet required (such as prior to surgery, to control excessive bleeding, or to defer or avoid splenectomy)? Please provide current platelet count and date collected: Date: / /. Kawasaki Disease Lambert- Eaton myasthenic syndrome Moersch-Woltmann (Stiff-man) Syndrome (unresponsive to other therapies). Multifocal motor neuropathy Yes No Does the patient have progressive, symptomatic multifocal motor neuropathy? Yes No Was the diagnosis based on electrophysiologic findings that rule out other possible conditions that may not respond to this treatment?

9 Multiple Myeloma Myasthenia Gravis Neonatal Alloimmune Thrombocytopenia (NAIT) (also known as Fetal Alloimmune Thrombocytopenia or FAIT). Neonatal Hemochromatosis (prophylaxis). Opsoclonus- myoclonus Paraneoplastic opsoclonus-myoclonus- ataxia associated with neuroblastoma Parvovirus B19 infection (chronic- with severe anemia). Polymyositis in persons who are resistant to first and second line therapies Post- transfusion purpura Preparation for thymoma surgery (to prevent myasthenia exacerbation). Primary humoral immunodeficiency diseases: Please indicate which of the following applies to the patient: Congenital agammaglobulinemia (X-linked agammaglobulinemia) Common variable immunodeficiency Hyper IgM syndromes X-linked immunodeficiency with hyperimmunoglobulin M Hypogammaglobulinemia Wiscott- Aldrich Syndrome Immunodeficiency with thymoma (Good Syndrome) Severe combined immunodeficiency None of the Above Rasmussen encephalitis (Rasmussen's Syndrome).

10 Relapsing- remitting multiple sclerosis (MS). Yes No Have standard approaches ( , interferons) failed, become intolerable, or contraindicated? Please identify below: Standard approaches failed Standard approaches have become intolerable Standard approaches are contraindicated Continued on next page GR-68305 (9-17). Aetna Precertification Notification Immune Globulin (IG) Therapy Medication 503 Sunport Lane, Orlando, FL 32809. and/or Infusion Precertification Request Phone: 1-866-503-0857. Page 3 of 3 FAX: 1-888-267-3277. (All fields must be completed and legible for Precertification Review.). For Medicare Advantage Part B: FAX: 1-844-268-7263. Patient First Name Patient Last Name Patient Phone Patient DOB. G. CLINICAL INFORMATION (continued) Required clinical information must be completed in its entirety for all precertification requests.